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The procedure described by CPT® Code 28116 refers to an ostectomy, specifically the excision of a tarsal coalition. A tarsal coalition is characterized by an abnormal connection or fusion between two or more tarsal bones in the foot, which can significantly restrict the normal range of motion. This condition may arise from various causes, with congenital factors being the most common; however, it can also develop as a result of acquired conditions such as infections, arthritis, or traumatic injuries. Clinically, individuals with a tarsal coalition may experience a range of symptoms, including pain during ambulation or standing, fatigue in the legs, muscle spasms, flatfoot deformity, limping, and stiffness in the foot and ankle. The surgical approach to address this condition is contingent upon the specific tarsal bones involved in the coalition. During the procedure, the abnormal connections—whether they consist of bone, cartilage, or fibrous tissue—are surgically excised. To promote proper healing and restore function, surrounding fat and/or muscle tissue is interposed between the affected bones. Finally, the overlying soft tissues are meticulously closed in layers, and the foot is immobilized in a cast to ensure stability during the recovery process.
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The procedure of excising a tarsal coalition is indicated for patients presenting with specific symptoms and conditions related to the abnormal fusion of tarsal bones. The following indications are explicitly recognized for this surgical intervention:
The surgical procedure for excising a tarsal coalition involves several critical steps to ensure effective treatment and recovery. The following procedural steps are outlined:
Post-procedure care following the excision of a tarsal coalition is essential for successful recovery. Patients are typically advised to keep the foot immobilized in a cast for a specified duration to ensure proper healing. Pain management strategies may be implemented to address any discomfort experienced after the surgery. Patients should also be monitored for signs of complications, such as infection or improper healing. Follow-up appointments are crucial to assess the healing process and to determine when it is appropriate to begin rehabilitation exercises aimed at restoring mobility and strength to the foot and ankle. Gradual weight-bearing activities may be introduced as healing progresses, under the guidance of a healthcare professional.
| Short Descr | REVISION OF FOOT | Medium Descr | OSTECTOMY TARSAL COALITION | Long Descr | Ostectomy, excision of tarsal coalition | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 161 - Other OR therapeutic procedures on bone |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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